Provider Demographics
NPI:1306146121
Name:BALLANTYNE VISION CARE LLC
Entity type:Organization
Organization Name:BALLANTYNE VISION CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLANTYNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-383-0134
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-0305
Mailing Address - Country:US
Mailing Address - Phone:719-383-0134
Mailing Address - Fax:719-404-1825
Practice Address - Street 1:302 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1430
Practice Address - Country:US
Practice Address - Phone:719-383-0134
Practice Address - Fax:719-404-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA106109OtherMEDICARE GROUP PTAN
CO93920288Medicaid
CO1306146121OtherNPI FOR LAMAR OFFICE